HESI RN FUNDAMENTALS EXAM 2023 UPDATED.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A.Left brachial vein B.Right cephalic vein C.Dorsal side of the right wrist D.Right upper extremity (ANS- B Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation (B). The basilic vein of the arm is used for IV access, not the brachial vein (A), which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist (C) are visible, they are fragile and using them would be painful, so they are not recommended for IV access. (D) is not specific enough for documenting the location of the IV access. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A.Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B.With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C.Assist the client to a standing position by gently lifting upward, underneath the axillae. D.Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair. (ANS- B Rationale: (B) describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed (A). Clients should never be lifted under the axillae (C); this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck (D); this places undue stress on the nurse's neck and back and increases the risk for a fall. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted. (ANS- D